Health & Fitness Waiver

Please read and sign the release form before participating in any activities with Stacey McKenzie Pilates.

Please either download and email this form or fill it out here.

Once completed, kindly email back to staceymckenziepilates@gmail.com

Download Health Waiver (pdf)

Fill out form here if not downloading:

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Emergency Contact Name:

First Name

Last Name

Emergency Contact Phone:

(###)

###

####

Agreement 1- PROMISES

This agreement is between myself, Stacey McKenzie Pilates and its employees, contractors, lessors, and affiliated persons and organizations in consideration for fitness instruction and the method created by Joseph H. Pilates, I make the following statements and promises: I acknowledge and agree that the activities in which I am about to engage involve physical activity which may from time to time be strenuous and which carries the inherent risk of injury, including death. I must: (1) judge my own capabilities with respect to participating in classes and other activities with Stacey McKenzie; and (2) consult with a qualified physician before beginning any exercise regime and from time to time thereafter pursuant to my physician's recommendations. I hereby assume all risk of injury, illness, damage or loss to me or to my property that might result, including, without limitation, any loss or theft of any personal property. I acknowledge that it is my responsibility to inform Stacey McKenzie and personnel immediately should an injury occur. I hereby assume all risk of injury, illness, damage or loss to me and/or to my property that might result, including without limitation, in any personal property. I understand that all reasonable efforts will be made to ensure my physical safety.

Agreement 2- PREGNANCY

If I am pregnant or if I become pregnant, I will discontinue the training until I receive written consent from my doctor.

Agreement 3 - INDEMNIFICATION

In consideration of my participation in the classes offered by, and use of the facilities and equipment located at 95 Old Post Rd N. Red Hook, NY 12571 I hereby: (1) waive and release Stacey McKenzie its principals, officers, owners, agents, employees, instructors, independent contractors and affiliates from any and all claims, demands, causes of action, damages, expenses (including attorney's fees), losses, and liabilities of any type whatsoever, past, present, or future arising out of or relating to my activities at Stacey McKenzie (collectively, "claims") (excepting claims caused by grossly negligent, reckless or willful conduct, except to the extent such a waiver is permitted under applicable law); (2) agree to indemnify and hold harmless the Stacey McKenzie parties with respect to any and all claims for which I may be liable to others; and (3) covenant not to sue the Stacey McKenzie parties with respect to any claims. The foregoing waiver of claims, agreement to indemnify, and covenant not to sue apply whether or not I am participating in a class, using any equipment, or acting under the supervision of Stacey McKenzie personnel, at the time of any occurrence, act or omission.

CANCELLATION POLICY

I am aware that there is a 24-hour cancellation policy and that I will be charged the full session fee for all late canceled appointments.

NO REFUNDS

I understand that no refunds will be given on class packages. All used sessions expire within 120 days of purchase. Sessions are non-transferable.

FINAL AGREEMENT

I have carefully read, fully understand, and agree to each provision of the foregoing agreement.

Today's Date

YYYY